It was always going to be hard for President Barack Obama to pass health care reform by the fall. Lately, there are signs it'll take a political miracle.
Democrats consider public insurance a must-have. To Republicans, it's a deal-killer. And nobody's figured out yet how to pay for the plan. An $80 billion deal with drug makers announced Saturday helps - but the price tag starts at a trillion-with-a-T.
"The shocker to me is that anyone is shocked," said Drew Altman, president of the Kaiser Family Foundation. "With the details on the table, it has finally gotten real."
If Obama has any hope of pulling it off, the next month is critical. Here are the five things supporters say he needs to do - and fast - to make it happen.
1. Put the bully pulpit to work
Obama's hands-off approach to health care seems to have run its course, some Democrats say.
That doesn't mean he'll be attending negotiating sessions on Capitol Hill, but Obama's supporters are clamoring for him to campaign for health care like his own election was on the line.
In a way, they say, it is - because the fate of health care may well determine the course of his presidency, given how far out on the limb he is in calling for a bill this year.
Obama held one major health care event during each of the last two weeks. On Wednesday, he will host ABC News at the White House for a day of interviews and a health-care town hall. An aide said Obama will do as much as he can, but was non-committal about how much more he'll do.
But from the diaries of Daily Kos to the party establishment, Democrats say they want a sharper message from a president who has tried not getting too involved.
"I understand that Obama's White House team has to juggle a lot of issues; I've been there," Democratic strategist Paul Begala wrote on CNN.com. "But if the president wants to pass his ambitious health care reform, he's going to have to put other, worthy ideas on the back burner."
Former Clinton Labor Secretary Robert Reich called for more drastic action: "Put everything else on hold. ... By pushing everything at once, you take the public's mind off the biggest goal, diffuse your energies, blur your public message and fuel the demagogues who say you're trying to take over the private sector."
2. Keep it at $999,999,999,999
Well, maybe not literally. But in the Senate Finance Committee - the committee that health care players say matters most - lawmakers are taking a page from car salesmen and clothiers. They want to push the bill underneath an imaginary, mental price threshold, and in the case of health reform, it is $1 trillion.
The problem is, what do you leave out?
The main ideas for cost-cutting focus, not surprisingly, on giving fewer and fewer people government assistance to get insurance. Finance Committee Chairman Max Baucus (D-Mont.) trimmed the amount of subsidies available to low-income families to purchase coverage. And the Medicaid expansion may not be as large as once hoped.
That's exactly what liberals are afraid of - that every cut takes them farther away from their longtime dream of coverage for all. In fact, Obama in the not-so-distant future may have to worry that all this number-crunching will cost him the support of his most liberal supporters, who seriously question whether anything less than $1 trillion truly fulfills his campaign promises.
But the cold reality is that anything much over a trillion probably won't make it out of the moderate Finance Committee. The strategy is a nod to what they view as the political peril of a big price tag at a time when Americans are growing more concerned that Obama will ust the budget.
3. Decide if bipartisanship matters
This is a big one for Obama and the Democrats, a decision that could shift the entire debate overnight.
Democrats have said they're willing to wait until October before "going nuclear" and invoking Senate rules that require a simple 51-vote majority, effectively cutting the GOP out of the negotiations.
But that means months of trying to string together support across the board - from single-payer liberals to Iowa Sen. Chuck Grassley, ranking Republican on the Finance Committee. So far, it's not working, and it's keeping people like Baucus from throwing his efforts behind a robust public insurance option.
Now some Democrats are saying enough's enough - that these months are too precious to try to eke out a few Republican votes, when negotiations should focus instead on getting a workable bill. In other words, bag bipartisanship long before October.
One grumble on the Hill: Obama has sent confusing messages. Days after writing a letter to key Senate negotiators that he "strongly" believes in a public insurance option, he told them in a private White House meeting that he's flexible on everything except the outcome: legislation on his desk by the fall.
Some read that as a sign he wants to stick with bipartisanship for now.
Obama got one piece of good news this week: Two big newspaper polls showed more than 70 percent of Americans want a public insurance option. Yet inside the Senate, support is much softer, with both Republican Dick Lugar and Democrat Dianne Feinstein urging Obama to slam on the brakes and study the idea more.
At some point, Obama, House Speaker Nancy Pelosi (D-Calif.) and Senate Majority Leader Harry Reid (D-Nev.) will need to decide how far they will push the public option and, ultimately, what is more important: two-party support or a public plan.
4. "Let's Make a Deal: Industry Edition"
Talk about good timing. The deal announced Saturday - between the pharmaceutical industry, Baucus and the White House - for $80 billion in savings on drug costs challenged the emerging story line that health care reform by this fall was in real jeopardy.
So what Obama needs now are more big-dollar deals like that to help him foot the bill -- and show momentum is on his side.
There are some likely targets. Perhaps Obama will win over the influential American Medical Association, which is opposed to a Medicare-like public option, with a more vigorous proposal to rein in the costs of medical malpractice lawsuits - easily their No. 1 issue.
House Democrats already are wooing physicians by pledging to address another priority - a permanent fix to the Medicare payment formula.
The agreement with the drug makers also showed that the Democratic deal making was more aggressive than previously known - suggesting other deals may be in the works -- and it earned grudging respect from Republicans who privately acknowledged it as a skillful move.
5. Decide what he truly wants
Obama probably knows how far he can bend and still get a bill he'll sign. One problem: No one else knows, and he's been careful not to define what success means.
He has laid out three principles that leave plenty of wiggle room: Slow the growth in health care costs, expand coverage, and guarantee choice of doctors and private and public insurance plans.
But what does he consider a public insurance plan? Sen. Kent Conrad (D-N.D.) is pitching nonprofit insurance cooperatives - an idea could lure some Republicans and moderate Democrats - but do they fit Obama's definition of providing competition for private insurers and keeping them honest?
Obama has yet to say.
The liberals in his party consider the Conrad plan a non-starter. The divide is not isignificant. At the same time that Sen. Chris Dodd (D-Conn.), the stand-in chairman of the Health, Education, Labor and Pensions Committee, was telling legions of activists on a conference call Thursday night that he was fully committed to a public option, an outline of the Finance Committee bill had leaked out.
It offered no public plan. Only Conrad's proposal was included - and even it was tagged as an "open issue."
Written by Carrie Budoff Brown